ESWL and Diabetes: No Established Causal Relationship
Based on the most recent and highest quality evidence, there is no conclusive link between ESWL and the development of diabetes mellitus. The 2025 European Association of Urology guidelines explicitly state that the relationship between shock wave lithotripsy and diabetes remains unclear, with no conclusive evidence of long-term adverse effects 1.
Current Evidence Assessment
Guideline Position
The most authoritative and recent guidance comes from the 2025 EAU guidelines, which directly address this concern by stating: "The link between SWL and hypertension/diabetes remains unclear, with no conclusive evidence of long-term adverse effects" 1. This represents the current consensus position from the leading urological society in Europe.
Conflicting Research Evidence
The evidence base shows contradictory findings:
The largest and most recent population-based study (2019) involving 106,963 patients with median follow-up of 6.6 years found no increased risk of diabetes in patients undergoing ESWL compared to ureteroscopy (hazard ratio 0.97,95% CI 0.91-1.02; p = 0.25) 2. This study used multivariable analysis controlling for age, gender, region, income, year of treatment, and comorbidity index.
An older 2006 study with 19-year follow-up reported increased diabetes prevalence in ESWL patients (OR 3.23,95% CI 1.73-6.02, p <0.001), with risk related to number of shocks and treatment intensity 3. However, this study had significant methodological limitations including smaller sample size and potential selection bias.
Critical Analysis of the Evidence
The 2019 population-based study should be prioritized because it:
- Represents the most recent high-quality evidence 2
- Includes a substantially larger patient cohort (>100,000 patients vs. 630 patients) 2
- Uses more rigorous statistical methodology with multivariable adjustment 2
- Directly contradicts the earlier 2006 findings 2, 3
The older 2006 study, while raising important safety concerns, has been effectively superseded by more robust population-level data 3.
Clinical Implications
Patient Counseling
- Inform patients that current evidence does not support a causal relationship between ESWL and diabetes development 1, 2
- Acknowledge that historical concerns existed but have not been confirmed by recent large-scale studies 2, 3
Risk Factors to Monitor
While ESWL itself does not appear to cause diabetes, certain patient factors increase complication risk:
- Pre-existing diabetes increases risk of post-ESWL complications (p = 0.02) 4
- Larger stones (11-30 mm) are associated with higher complication rates 4
- Bilateral treatment may increase other adverse outcomes 3
Common Pitfall
Do not withhold ESWL based on diabetes concerns alone, as this would deprive patients of an effective, minimally invasive treatment option without evidence-based justification 1, 2.